On 23 June, the Free State Department of Health reportedly opened the "first municipal clinic in South Africa which solely operate on solar power and [that] has two 2500 litre each water catchment systems to ensure uninterrupted service".
Free State Premier Sisi Ntombela opened the Parys Clinic in the Ngwathe District. The clinic was built by Sasol on land the municipality made available and the health department furnished it.
It is said the clinic was built based on the Ideal Clinic Model.
Elsewhere in the province, however, many public healthcare users are not so lucky.
At present, there are 218 clinics in the Free State servicing about 2.2 million public healthcare users out of the province's 2.7 million population. A total of 83 of them have been accredited with Ideal Clinic Status, meaning they have adequate infrastructure, adequate staff members, reasonable waiting periods, sufficient medicine and supplies, as well as good administrative processes and adequate bulk supplies. The Ideal Clinic programme "aims to systematically transform all primary healthcare facilities to meet national standards in preparation for National Health Insurance". The Free State health department's own figures, however show that the number of these clinics took a dip in the last few years signalling some real challenges the province will have to overcome in preparation for NHI.
Not so ideal
Despite being accredited with Ideal Status, healthcare users at some of these clinics are often left frustrated by staff shortages, long waiting periods, and inadequate infrastructure.
Last month, Spotlight visited two clinics in Mangaung - Thusong Clinic and the MUCPP Community Health Centre that are both accredited as ideal clinics.
During the visits, Spotlight observed the clinic gates open at 7 am. Both clinics are supposed to provide services from 8 am until 17:00 pm, but some nurses only arrived at 8 am. Between 8 am and 10 am some of the nurses were catching up and having coffee while healthcare users waited to be seen. It was only at around 10 am when both facilities started seeing the first healthcare users.
By then, at Thusong Clinic, one of the health workers informed the queuing healthcare users who have brought sick children to the clinic that they cannot be assisted as the clinic has been without flu medications for children since 2020.
On the wall, there was a note signed by management that states a maximum of two hours of waiting time is allocated, but patients report that they usually spend five hours at the facilities.
COVID-19 to blame
According to the Chief Director of District Health Services at the Free State Department of Health, Dr Grace London, many ideal clinic services in the province have indeed deteriorated due to the COVID-19 pandemic.
She says the department's focus for clinics to be accredited with ideal status is the infrastructure, which the department was not able to maintain and sustain for two years during the pandemic.
According to London, the department is doing its best to ensure that quality service continues to be provided at all its primary healthcare facilities.
"When COVID-19 broke out, we faced a challenge where there was no maintenance at clinics for two years. We lost many people who were ensuring the quality of the clinics during that time, which ranged from cleaners, nurses, and clerks. We were left with no operational managers and there was a challenge with consumables, meaning medication would be late and could not be delivered to the facilities on time. This left us with a backlog of unavailable medication in facilities. These are just some of the factors that caused us to regress," she says.
Ideal clinics: a timeline of the numbers
In November 2015, the first 22 of 222 clinics were accredited with ideal clinic status in the Free State. According to an ideal clinic status report that was released by the Free State Department of Health, the best performing district in 2015 was Xhariep, followed by Mangaung Metro, Fezile Dabi, Thabo Mofutsanyane, and Lejweleputswa.
By the 2016/17 financial year, 79 of the 222 clinics assessed achieved ideal status. The following financial year, the number climbed to 79 clinics that achieved ideal status. In 2018/19, only 218 clinics were assessed. Of those, 153 achieved ideal status. However, by the following year, when COVID-19 hit, the number of clinics with ideal status dropped to 94.
Currently, only 83 of the 218 have ideal status and the best performing district - Xhariep with 65% of its clinics compliant compared to the worst-performing district - Lejweleputswa with only 7% of its clinics compliant with ideal status.
London tells Spotlight all clinics are enrolled and assessed, and those that are excluded are the ones under refurbishment, which will then be included during the following intake.
Explaining the process, she says from the Office of Health Standards Compliance, an ideal clinic assessment team consisting of operational managers, local area managers, and district managers among others, visits the facilities to assess them based on the ideal clinic assessment tool.
"Unfortunately, some clinics in the province will never be able to achieve ideal status because of the infrastructure and the size. Often these are clinics that operate from Reconstruction and Development Programme (RDP) structures, which have been converted into clinics." She says these clinics are automatically disqualified because of their size, which cannot accommodate the flow of patients.
In November last year, London briefed the national health department. In a presentation reflecting on the successes, failures, and future plans of the Ideal Clinic Realisation and Maintenance (ICRM) programme in the Free State, she said overall the province was performing poor on patient safety, which is one of the ideal clinic elements many clinics failed. This, she said, was mostly due to the lack of security at many clinics. Spotlight previously reported on safety and security at Free State health facilities here.
Based on patient experiences of care reports, some elements clinics performed poorly on included cleanliness and infrastructure.
London says some of the challenges that prevent many clinics from achieving ideal clinic status also include slow supply chain management processes where there is ineffective contract management for the supply of cleaning equipment and poor quality of equipment. She says another challenge is also the training of professional nurses, which is being delayed due to capacity and COVID-19 limitations.
She also noted some successes of the programme and in her presentation said patient records have been linked to the health patient record system, which now enables "quick file retrieval leading to improved patient waiting time" at clinics. The department also procured "high-density filing cabinets to improve on patient records filing and retrieval" at 12 clinics in Mangaung and 17 facilities in Fezile Dabi District received cabinets.
Money matters
In the previous financial year, Health MEC Motseng Tsiu budgeted R65 million for primary healthcare infrastructure, which was meant for procuring new health facilities, refurbishments, upgrading, and the maintenance of existing facilities.
Among the facilities upgraded last year was Opkoms Clinic in Mangaung. Yet some months later in May this year, EFF MP Paulnita Marais flagged several break-ins and security breaches at the clinic during a parliamentary question. Marais wanted to know the extent of the damage assessed by the health department caused by the break-ins in the past few months and what the reasons were that the department has placed no security at the specified clinic despite the numerous break-ins.
In her budget speech in April this year, Tsiu said that it is important to address the backlog of health infrastructure maintenance and allocated R741.2 million of the R12.7 billion budget towards this. This will be used for refurbishments, upgrades and new clinics, and hospitals, among others.
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Tsiu acknowledged that half of the primary healthcare facilities in the province "did not meet the threshold to be defined as ideal clinics".
"Prior to COVID-19, we were at 69% compliance. This declined to 43% in 2020 as a result of COVID-19, and we have shown signs of recovery, with an achievement of 54% in 2021/22," she said.
"The department is committed to ensuring our facilities regain the ideal status. This, we will achieve by making critical appointments, such as Operational Managers, cleaners and Pharmacy Assistants. Much of our effort will also go into conducting ongoing maintenance, which has suffered partly because of funds being reprioritised in response to the COVID-19 pandemic."
London tells Spotlight both these clinics - Opkoms and the new Parys Clinics are part of the department's programme to address the maintenance backlog from the last two years.
"They are now both in the ideal clinic standard. In fact, the Opkoms Clinic was accredited ideal status in November last year, and I am certain that the Parys Clinic will also be accredited after it has gone through the assessment process," says London.
According to the health spokesperson for the Democratic Alliance in the Free State Mariette Pittaway, the ideal clinic system is useless and does not serve healthcare users.
"The system is implemented but the services do not improve because once an ideal status is achieved, they celebrate only on that day and things go back to the way they were before. The department will refurbish clinics, spending millions of money and fail to maintain them to keep the status. As a result, clinics deteriorate and continue to offer bad service to members of the community," she says.
